title: Improving outcomes by changing hemodialysis practice patterns.
abstract: OBJECTIVE
  This review examines recent advances in understanding of how clinical outcomes for hemodialysis patients may be improved by achieving longer or more frequent treatment times, lower ultrafiltration rates (UFRs), improving nutritional status, and individualizing dialysate composition. This review also discusses the controversy related to timing of dialysis initiation.
  
  
  RESULTS
  Many observational studies and several randomized controlled trials indicate longer dialysis treatment times, particularly nocturnal dialysis, and/or more frequent dialysis improve morbidity and mortality. Recent evidence also suggests that lower UFR and more consistent achievement of 'dry weight' may help minimize the damage from myocardial stunning and chronic volume overload that occurs in the majority of patients who receive conventional hemodialysis during the day with a standard schedule of 3-5 h, 3 times a week. Other aspects of the dialysis procedure such as appropriate estimated glomerular filtration rate for dialysis initiation and individualizing dialysate composition may also minimize cardiovascular risk. Finally, several studies have highlighted the benefits of oral nutritional supplementation (ONS) during dialysis.
  
  
  CONCLUSIONS
  Greater treatment times per week with slower UFR, consistent attainment of 'dry weight', individualized dialysate prescriptions, and administration of ONS to malnourished patients are likely to reduce hospitalizations and improve survival in this high-risk population of end-stage renal disease patients.
authors.affiliation: Vanderbilt University Medical Center, Nashville, Tennessee, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Fissell
authors.forename: Raymond M
authors.initials: RM
authors.lastname: Hakim
mesh_terms: D000740:Anemia / Q000209:etiology / Q000628:therapy; D000925:Anticoagulants / Q000008:administration & dosage; D015312:Hemodialysis Solutions; D006801:Humans; D006973:Hypertension / Q000209:etiology / Q000517:prevention & control; D017379:Hypertrophy, Left Ventricular / Q000209:etiology / Q000517:prevention & control; D009752:Nutritional Status; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D055502:Secondary Prevention; D013997:Time Factors; D016896:Treatment Outcome; D062666:Vascular Access Devices
chemical_list: D000925:Anticoagulants; D015312:Hemodialysis Solutions